SUTHERLAND HOSPITAL OUTPATIENT CLINICS

FAX TO: 9540 8067
PHONE ENQUIRIES: 9540 7067	

REFERRAL DATE: 		<<Miscellaneous:Date>>

OUTPATIENT CLINIC SERVICE: 	<<CLINIC REFERRING TO>>

<<Choose from below>>
DIABETES
<<Diabetes Outpatient Clinic>>
	RENAL
<<Renal>>	RESPIRATORY FAILURE
<<Respiratory Failure>>	
ENDOCRINE
<<Endocrine>>
	RENAL PALLIATIVE CARE
<<Renal Palliative Care>>	RESPIRATORY OPC
<<Respiratory Outpatient Clinic>>	
REHABILITATION
<<Rehabilitation>>
	NEUROLOGY
<<Neurology>>
	RESPIRATORY ASSESSMENT
<<Respiratory Assessment>>	
	NEUROLOGY/ REBABILITATION
<<Neurology/Rehabilitation>>	SLEEP CLINIC
<<Sleep Clinic>>	

REASON FOR REFERRAL (Mandatory For ALL Referrals)
<<Reason for referral>>	TYPE OF DIABETES:
<<If patient has Diabetes, please specify type:>>	

REFERRING DOCTOR
NAME: <<Doctor:Name>>	PROVIDER	<<Doctor:Provider Number>>	
ADDRESS:
<<Doctor:Full Address>>	PHONE
FAX
EMAIL	<<Doctor:Phone>>
<<Doctor:Fax>>
<<Doctor:E-mail>>	

PATIENT INFORMATION
NAME: <<Patient Demographics:Full Name>>	GENDER :  <<Patient Demographics:Sex>>  	
COUNTRY OF BIRTH: <<Patient Demographics:Country of Birth>>	DATE OF BIRTH: <<Patient Demographics:DOB>>	
ADDRESS
<<Patient Demographics:Full Address>>	HOME: <<Patient Demographics:Phone (Home)>>	

WORK: <<Patient Demographics:Phone (Work)>>	

MOBILE: <<Patient Demographics:Phone (Mobile)>>	

E-Mail <<Patient Demographics:E-mail>>	

MEDICARE NUMBER
<<Patient Demographics:Medicare Number>>	PENSION NUMBER
<<Patient Demographics:Pension Number>>	
DVA NUMBER
<<Patient Demographics:DVA Number>>	HEALTH INSURANCE
<<Patient Demographics:Health Insurance>>	

TRANSLATOR REQUIREMENTS	 <<Translator Required>>	LANGUAGE 	 <<If yes, language required>>	

PATIENT CONSENT	   <<Patient Consent>>	ABORIGINAL or TSI 	 <<Aboriginal or TSI>>	

CLINICAL INFORMATION
PAST MEDICAL HISTORY	
<<Clinical Details:History List>>
<<Any other relevant history/diagnosis>>	
ALLERGIES
<<Clinical Details:Allergies/Adverse Reactions>>	
CURRENT MEDICATIONS
<<Clinical Details:Medication List>>	
INVESTIGATIONS
<<Summary:Investigation Results (Selected)>>	
SOCIAL HISTORY
<<Clinical Details:Social History>>	

SMOKING STATUS
<<Clinical Details:Smoking>>	ALCOHOL USE
<<Clinical Details:Alcohol>>	
EXERCISE 
<<Exercise>>	DIET 
  <<Diet>>	

GP SIGNATURE		DATE	<<Miscellaneous:Date (short)>>